Patient Survey

Name

Email

Please rate the following:

A. YOUR APPOINTMENT:

Ease of Making an Appointment
PoorFairGoodVery GoodExcellentN/A

The Efficiency of the Check-In Process
PoorFairGoodVery GoodExcellentN/A

Waiting Time in the Reception Area
PoorFairGoodVery GoodExcellentN/A

Waiting Time in the Exam Area
PoorFairGoodVery GoodExcellentN/A

B. OUR STAFF:

The Friendliness and Courtesy of the Receptionist
PoorFairGoodVery GoodExcellentN/A

The Caring concern of our Nurses/Medical Assistants
PoorFairGoodVery GoodExcellentN/A

C. YOUR VISIT WITH THE PROVIDER:

Willingness to Listen Carefully to You
PoorFairGoodVery GoodExcellentN/A

Taking Time to Answer your Questions
PoorFairGoodVery GoodExcellentN/A

Amount of Time Spent with You
PoorFairGoodVery GoodExcellentN/A

D. YOUR OVERALL SATISFACTION WITH:

Our Practice
PoorFairGoodVery GoodExcellentN/A

The Quality of your Medical Care
PoorFairGoodVery GoodExcellentN/A

How did you Hear About our Office?
Family/FriendInternetPrimary/Other DoctorRadioOther

Would you Recommend the Provider to others?
YesNo

If there is any we we can improve our services to you, please tell us about it:

Are you:
A New PatientA Returning Patient